Friday, December 23, 2016

Schizophrenia is not a neurodevelopmental disease

Professor Sir Robin Murray confesses to mistakes in an end of research career mea culpa (see article). He questions whether schizophrenia is a neurodegenerative disease and accuses psychiatrists of refusing to accept the evidence, clinging to the "nihilistic view that there exists an intrinsically progressive schizophrenic process". This is what he believed once! He makes much of the fact that he did not sufficiently take into account the effects of medication. He even admits that he was surprised the neurodevelopmental theory of schizophrenia achieved such widespread acceptance. As far as he is concerned, saying that schizophrenia is a neurodevelopmental disease is at least overstatement, with the evidence against it.

Murray also admits that he ignored social factors in the aetiology of schizophrenia for 20 years. Like me (eg. see previous post), he points out that even social psychiatrists, such as Paul Bebbington and Julian Leff, tend not to regard social factors as causal.

Don't think, though, that this means Murray is saying critical psychiatry was right all along. He still believes the "final common pathway underlying psychosis is excess synthesis of presynaptic dopamine". His recommendation to newly qualified psychiatric researchers is to throw themselves into "examining gene x environment interactions and epigenetics", or if they are not clever enough, to go instead into neurochemical imaging, because "at least the pictures of the brain are pretty". The silly chump also still promotes ideas such as tobacco use causing psychosis (see eg. previous post).

19 comments:

Don't Robin bother with the 'Mea Culpa'Robin.......what does he want - sympathy? Just at the very least apologise to all those who have suffered because of the conceit and herd mentality of psychiatrists and the appalling way those in positions of influence can perpetuate ignorant theories even after they have been proved wrong

PS The Psychologist magazine has adopted the term that a person has a 'schizophrenic diagnosis' which challenges the labelling of somebody as 'schizophrenic' and educates more practitioners about mis-using the term 'schizophrenia'

Thanks for the publicity, Duncan. Perhaps i could make two points. In our article on tobacco use and risk of psychosis, we concluded cautiously that "The possibility of a causal link merits further examination."; and, of course, the initial suggestion that cigarette smoking might cause lung cancer was dismissed with derision in the 1950s. I found it useful to be asked to look again at my previous beliefs. Perhaps some self reflection might be a useful exercise for others too. Although Critical Psychiatry is often very sceptical about orthodox psychiatry, it doesn't seem to have developed much capacity for self criticism. Two contrasting examples. Firstly, much research has now supported the organisation's scepticism about the unthinking advocacy of prophylactic antipsychotics. On the other hand, the prejudice shown by some of the leading lights in Critical Psychiatry towards the dopamine hypothesis appears increasingly out of touch; recent research has demonstrated that some social factors such as child abuse and social stress increase an individual's dopamine release, thus providing a mechanism to understand how adversity can provoke the particular symptoms that psychiatrists term psychosis. Merry X-mas and Happy Self-Reflection in 2017 from a "Silly Chump"

There wasn't much 'self reflection' if Robin needed to be asked to do that.....surely reflection should be self motivated and ongoing throughout a career -especially when the practitioner's beliefs have such an impact on vulnerable people's lives.

Thanks for your interest. People of course believe all sorts of things. One common false assumption is concluding causality from mere association and I think it's always important to be sceptical about this link. However, I think the evidence for smoking causing cancer is more than this, although not all lung cancer, especially adenocarcinoma, is caused by smoking.

I've created another post following your comment. You may also be interested in a post on my personal blog.

Of course people tend to be defensive. However, I'm not sure if I agree with you about the lack of self-reflection within critical psychiatry. There are excesses and I have tried to counter these. Actually, I wish people would engage more with what I say about critical psychiatry. There are a variety of views within critical psychiatry and it is a broad church. As far as dopamine is concerned, it's the more specific speculation about aetiology of schizophrenia that I object to.

I agree with all you say above Duncan. In my view the dopamine hypothesis says nothing about aetiology. Its simply a mechanism through which factors such as childhood adversity, intrusive life events, and use of illicit drugs can have their effect in increasing risk of psychosis

Perhaps I might also invite Cobweb who made early posts to actually read my article. There he/she would see that I don't believe that schizophrenia exists as a real entity (and therefore don't use the term in my clinical practice).

I have 'actually read the article' thank you Robin. Maybe, to be charitable, the 'silly chump' label was meant to refer mostly to your comment about 'pretty pictures'?? My own focus was the lack of moral action when psychiatrists carry on with practices they have no faith in - but fail to speak out until 'safe' to do so.We can all be chimps at times but a more appropriate description for Jim Birley (past president of College of Psychiatrists) , with reference to his comment about his own episode of 'psychosis' would be 'Twonk'. (see definition in urban dictionary). It could also perhaps be used as a term of endearment sometimes.

- In an admiring article in the Psychiatric Bulletin 2014, written by Peter Tyrer, (former Editor J Of Psych, and R.Van Voren) the authors described Jim Birley as having developed an unequivocal manic episode - this caused by the stress of overwork at the College. Jim B. is quoted as saying 'It was very pleasant and I would not have minded if it had gone on a little longer'.

The post of President is open for voting right now. What qualities would make the most difference?

Hi Duncan, I think this is a very interesting article from Robin. I think it must have taken a good deal of courage to write it and to publish it in Schizophrenia Bulletin. I don't know Robin very well but we did meet at the Maudsley debate a few years back. I respect him as a thoughtful researcher and commentator. However, I was disappointed by his dismissal of critical psychiatry in his response to your blog. We have many failings as a network but I don't see how he can say that we are not open to 'self criticism'. There are many different opinions and outlooks in the network and some colleagues are very firm defenders of the role of psychotropics.

While Robin's self-critique is positive, even exemplary, it is clear that he remains firmly attached to the current paradigm. We attempted to map this a few years back in our BJPsych editorial. His observations, in this article at least, ignore the three issues that have concerned the current critical psychiatry movement since its origins about 15 years ago. First, on an epistemological levels, he is clearly still wedded to reductionism and the search for biological explanations for psychological problems. This is clearly expressed in the last paragraphs where he endorses epigenetics and neurochemical imaging as the way forward. Critical psychiatry has never dismissed biological research but we have challenged the biological reductionism that informs the current paradigm. Secondly, on a political level, his article continues to position psychiatric research as a purely professional endeavour. Academic researchers and their clinical collaborators are still the ones who will come up with the answers to madness and distress. There is, I am sorry to say, nothing here about collaboration with service-users being a priority. And yet, it is through the efforts of the service-user movement that many of the problems of our current psychiatric models and treatments have emerged. By way of contrast, a central aim of critical psychiatry has been to create the conditions in which real dialogue between the different stakeholders in the mental health field can take place. This requires a much deeper effort at professional self-critique than what is evident in Robin's article. Thirdly, there is no reflection on the ethical problems our profession has faced in the past 30 years. I am referring here to the systematic corruption of academic research by Pharma during this time. This corruption, which Robin must have observed over the course of his career, set the context in which so many of our academic colleagues became part of the 'herd'. Again, this is something that our critical psychiatry network has worked hard to expose and to challenge.

Sorry to be slow in responding – have been on holiday. First, let me defend Jim Birley who I greatly admired. I was working for him at the time of his "manic episode" and know that it caused him and his family much distress. I imagine that the quote that you, Cobweb, object to, resulted from his tendency to minimise any personal difficulties he had in life. Jim Birley was a lifelong advocate of working with service users, and spent much of his spare time, and not a little of his personal money, trying to improve social and work opportunities for his patients.

Thank you Pat for you’re the kinder of your comments. Re the others, firstIy I was not dismissing critical psychiatry. I am quite sympathetic to many of its aims. This was one of the reasons why I set up the Maudsley Debates , at which we once met, as a forum for professionals and service users to discuss contentious areas of psychiatry.

My enthousiasm for epigenetic studies and neurochemical imaging does not mean that I am wedded to the view that biological factors explain psychological problems. Such studies will not reveal the causes of psychosis but they may help us to understand how social risk factors impact on our biology; for example, we have recently learned that child abuse can cause long-lasting changes in both epigenetics and the dopamine system. Furthermore, much of our own recent research has been into the role of social factors such as child abuse, migration, and adverse life events.

I did not comment on the importance of service user research or on the invidious actions of those psychiatrists (and psychologists) who act as the unthinking mouthpieces for pharmaceutical companies, simply because I was not asked to discuss these topics. Perhaps I might entice you to read our recent article “Should psychiatrists be more cautious about the long-term prophylactic use of antipsychotics?” British Journal of Psychiatry, 2016, 209 (5) 361-365.

Hi Robin, thank you for your response. I did read your paper on antipsychotics when it came out and I found it encouraging that you and your co-authors were highlighting the potential damaging effects of long-term antipsychotic use. This is something that critical psychiatry has been pointing to for many years. I note that none of your co-authors is from the US. My own feeling is that American psychiatry has had a very damaging effect on our profession over the past 30 years or so. Robert Whitaker has been vilified by the APA for reaching conclusions that are not too dissimilar to your own. Have you read his 'Psychiatry Under the Influence' book? It would be good to see him receiving support from some 'establishment' figures on this side of the Atlantic. There was nothing in your paper about the role of Pharma (and its mouthpieces) in the promotion of the myth that 2nd generation antipsychotics were superior. I also accept that you have looked at social factors in much of your work but my point about reductionism stands. I do not believe that the social world can be reduced, or studied, as a series of factors. What is important is the meaning of events and this is what gets stripped away in positivist approaches. Life events such as migration have complex meanings and their impact cannot really be understood in isolation from the context. (see my paper "Towards a Hermeneutic Shift in Psychiatry": World Psychiatry, 13, 3: 241-243). I am not arguing that quantitative studies are never helpful but we need a much greater focus on meanings, relationships and values in our research and our clinical endeavours if we are really to move forward.

Duncan,I'm surprised more people don't consider that ""excess synthesis of presynaptic dopamine" might not be "excessive", but might in fact be the "normal" or expectable amount of dopamine that gets produced when people are often very isolated, terrified, alone, etc... people's brains exist in relation to and respond to the environment. There are reasons for changes in brain chemistry... I thought that's what John Read's research showed, that the brain changes associated with "schizophrenia" are very similar to from brain changes occurring in heavily traumatized or isolated children and adults...

You may know that according to E Fuller, this kitty is the real cause of schizophrenia - or rather the virus this cat carries around. So I think Robin isn't going far enough in his ideas about tobacco contributing to schizophrenia. It's really down to this kitty and its virus!

Actually Pat I don't think you understand epigenetics - it's not reductionist although you can do the arguments fine without it - that doesn't mean you shouldn't explore it if that's your interest. It's not mine but happens to be my partner's - that's OK. Your argument about service users is correct and I will have that conversation with Robin (who I like as we are both old Scottish socialists for one thing). For me personally knowing that stuff about dopamine super-sensivity was very important when I finally came off olanzapine - it is very difficult to distinguish relapse from withdrawal. I didn't exactly get that from Robin but I am really glad if the article will facilitate a different conversation between psychs and SUs. I don't know enough about critical Psychiatry but there are professionals who call themselves radical who want nothing less than a 360 degree turn epiphany to align exactly with their views. I got trolled on FB for questioning one of them. As for Duncan's query about why I think Psychiatry might implode. I have just sat in too many meetings where the analysis is so flaky. They can't do that any more with the new publishing rules.

I am neither a Psychiatrist or Academic, but a lowely Carer with two sons who suffer from Schizophrenia and a Grandson who has Autism. We were a 'normal' family until my first son's breakdown, 'high medication' for years now 15 stones in weight, smokes and sits most of the day, lives in a flat. 'Invisible' to the system. My other son lives with us' 'Negative' symptoms, and a different outcome. Always well dressed, Gardens, plays Table Tennis for the County, drives a Car, and excellent Golfer. The Question is: where would this son be without the Social Input from Family and OUR friends willing to help him and us.

The Dopamine theory sound about right, brought on via Adolescense anxieties, but nobody has explained the 'mutated' gene theory past on by a Parent who has neither Schizophrenia or Bipolar.

The Question is: it possible to come off this medication Olanzopine that I understands effects Dopamine without suffering a relapse due to more being released? or would Psychotherapy help initiall to manage the changes that would occur in the brain?

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